family planning By Dr bob John mbchb.pptx

Good notes from duttas text book gynaecology

1. F AMI L Y PLANNING BY OTYALUK PATRICK MBChB-4.2 KAYUNGA. SUPERVISOR –DR SANYU 1 •

2. Family planning services 2 D efinition: A re educational, comprehensive medical or social activities which enable individuals, including minors, to determine freely the number and spacing of their children and select the means by which this may be achieved.

3. 3 Family planning D efinition : I s the practice of controlling number of children in the family and the intervals between their births , particularly by artificial contraception or voluntary sterilization.

4. contraception The term contraception includes all measures temporary or permanent, designed to prevent pregnancy due to the coital act. Ideal contraceptive methods should be: highly (100%) effective, acceptive, safe, reversible, cheap, having non-contraceptive benefits, simple to use . 5

5. 5 Benefits of FP/Contraception Prevent s pregnancy related health risks in women : Prevent unintended pregnancies . Allow spacing & delay pregnancy in young women . Help limit family size . Reduce the need for the unsafe abortions.

6. 6 Reducing infant mortality and morbidity p revents closely spaced & ill timed pregnancies . Help prevent HIV/AIDS R educ es risk of unintended pregnancies in HIV + ve women C ondoms prevent unwanted pregnancies and STIs.

7. 7 Empowering people and enhancing education : H elp s people to make choices about their sexual and reproductive health . Helps women attain additional health education and participate in public life and employment . Having smaller families allow parents to invest more in each child .

8. 8 Reducing adolescent pregnancies : Adolescent age pregnancies are likely to end with preterm or LBW babies leading to high mortality and morbidity rates Many adolescent girls who become pregnant leave school which can cause implications on them, their families and the community. Slow population growth : FP is a key to slowing unsustainable population growth .

9. 9 B ring about certain social changes like ; To educate and motivate the sexually active and fertile couple to accept the small family norm. To increase the literacy rate specially amongst women in rural areas . To maximise the access of good quality , wide variety , client oriented family planning services and to fulfil the unmet need of contraception .

10. Components of FP services 10 Client education about FP methods; Counselling for informed choice and continuity; Initiating FP methods (screening, providing method and giving instructions on how to use); Routine follow up; Management of contraceptives related side effects and complications

11. 11

12. 12 1. Mechanical Male — Condom Female — Condom, diaphragm, cervical cap 2. Chemical ( Vaginal contraceptives) Creams — Delfen (nonoxynol- 9, 12.5%) Jelly — Koromex, Volpar paste Foam tablets — Aerosol foams, Chlorimin T or Contab, Sponge (Today) Combination Combined use of mechanical and chemical

13. METHODS OF CONTRACEPTION The available methods of contraception can be classified in many ways . traditional or folk methods ; Coitus interruptus Postcoital douche. Lactational amenorrhea Periodic abstinence (rhythm or natural family planning). 13

14. 5 Barrier methods; 14 Condoms (male and female) Diaphragm. Cervical cap vaginal sponge Spermicides.

15. 6. Hormonal methods ; Oral contraceptives Injectable Implantable long-acting progestin . In addition, the IUD and sterilization ( tubal ligation or vasectomy ) 15

16. Hormonal Emergency Contraception 16 It’s the care following consensual but unprotected sexual intercourse, and in some cases aggravated sexual assault. It is used in emergency. It is not a regular method of contraception

17. Indications of emergency contraceptives Unprotected intercourse Condom slips or breaks (condom rupture). Sexual assault or after being raped . Missed pills . 17

18. 18 EXAMPLES OF EMERGENCY PILLS; 1 ), Levonorgestrel pill 1 . 5 mg as a single dose (most commonly used ). 2). Estrogen-progestin pills 0.1 mg ethinyl estradiol +0.5mg levenorgestrel . Follow with the same dose 12 hours later. 3). Progestin-only pills with levonorgestrel or norgestrel a) . Levonorgesrel pills; 1.5 mg levonogestrel as a single dose. b). Norgestrel pills; 3 mg norgestrel as a single dose.

19. 19 4 ). Combined (estrogen-progestin) oral contraceptives containing Levonorgestrel , norgestrel , ornorethindrone .; a) Estrogen and levonorgestrel pills; 0.1 mg ethinyl estradiol + 0.5 mg levonorgestrel . Follow with same dose 12 hours later. b). Estrogen and norgestrel pills; 0.1mg ethinyl estradiol+ 1mg norgestrel . Follow with the same dose 12 hours later. c). Estrogen and norethindrone pills; 0.1mg ethinyl estradiol+2mg norethindrone . Follow with same dose 12 hours later.

20. SELECTED EXAMPLES OF EMMERGENCY PILLS WITH THEIR MOA LEVONORGESTREL PILL 1.5mg (LNG) Prescribed over the counter. Taken as soon as possible, preferably within 72 hours of unprotected sex. Dosage is 1.5mg as a single dose.

21. MODE OF ACTION (MOA ) Delays or inhibits ovulation. Prevents ascend of sperms by causing cervical mucus thickening. Tubal motility is impaired. Prevents fertilization by causing thinning of endometrium making it unfavourable for implantation. It is not an abortifacient .

22. 22 Ulipristal acetate (Ella) It is Selective Progesterone Receptor Modulator. Same mechanism of action as LNG. Dose: 30mg. Effective for up to 120 hours after unprotected intercourse .

23. IUCDs ( Paragard , Mirena , and Litetta ) Most effective form of emergency contraception . Effective up to 5days after unprotected intercourse. Prevents fertilization and also prevents implantation Causes inflammation of endometrium making it not favourable for implantation Contraindicated in : Active genital infection 23

24. 24 Mifepristone (RU 486) and Epostane Ideal for postcoital contraception, either by blocking progesterone production (epostane), or interfering with its action (mifepristone). Dose: A single dose of 100 mg is to be taken within 17 days of intercourse. Implantation is prevented due to its anti- progesterone effect. Pregnancy rate is 0–0.6 percent. Mifepristone is effective up to 17 days after intercourse (Weiss, 1993).

25. LONG ACTING REVERSIBLE CNTRACEPTION 25 Injectable DMPA Implants CuT Mirena

26. 26 Injectable DMPA Inj. Depo- Provera(DEPOMEDROXY PROGESTRONE ACETATE). Dosage : 150mg, intramascular every 3months. It can be used freely in breastfeeding women after 6weeks postpartum. It is contraception of choice in sickle cell anaemia (DMPA decreasese sickling crisis ). a nd in women with epilepsy.

27. Side effects 27 Irregular uterine bleeding. Bone loss there fore not preferred in adolescent and perimenopausal. Delay in return of fertility after stopping the method

28. 28 I mplants are a good choice for w o men of reproductive age who are sexually active and desire long- term, continuous contraception. A sub dermally implanted device containing the drug and coated with a compound to prevent fibrosis. IMPLATS PROGESTIN IMPLANTS

29. It has two preparations; Norplant system and implanon Norplant system has been phased out due to its persistence in contraceptive effects . Implanon System is a single rod sub dermal implant with 68 mg of the progestin, etonogestrel covered by ethylene vinyl acetate co- polymer . Similar to the Norplant System .

30. 30 Indications of contraceptive implants D elay s the next pregnancy for at least 2- 3 years. Desire a highly effective, long- term method of contraception. Experience serious or minor estrogen- related side effects with estrogen- progestin contraception. Have difficulty remembering to take pills every day, have contraindications or difficulty using IUDs

31. 31 Have completed their childbearing but are not yet ready to undergo permanent sterilization. Have a history of anemia with heavy menstrual bleeding. Intend to breastfeed for a year or two. Have chronic illnesses, in which health will be threatened by pregnancy.

32. PROGESTERONE- ONLY IMPLANTS Norplant (Levonorgestrel)- Reversible 6 capsules Subcutaneously 5 years Jadelle (Levonorgestrel) 2 rod 5 years 3. Implanon (Etonorgestrel) Reversible 32 1 rod Subcutaneously 3 years

33. 33 Absolute Contraindications W omen who have : Undiagnosed genital bleeding. Active thrombophlebitis or thromboembolic disease. Acute liver disease. Benign or malignant liver tumors. Known or suspected breast cancer.

34. 34 Relative Contraindications. Heavy cigarette smoking (15 or more daily) Women older than 35 years. History of ectopic pregnancy.

35. 35 Hypercholesterolemia . Hypertension . History of cardiovascular disease, including myocardial infarction, cerebral vascular accident, coronary artery disease, angina, or a previous thromboembolic event. Patients with artificial heart valves. Gallbladder disease Chronic disease, such as immunocompromised patients

36. 36 I mplanon Implanon is a single flexible rod 4 cm long, that contains 68 mg of 3- keto desogestrel ( etonorgestrel , the active metabolite of desogestrel ) dispersed in a core of ethylene vinyl acetate wrapped with a membrane of the same material. The hormone is released at an initial rate of about 67 µg per day decreasing to 30 µg after 2 years; concentrations that inhibit ovulation are achieved within 8 hours of insertion .

37. A steady state is achieved after 4 months; after which there is no accumulative effect . Designed to provide contraception for 3 years . Less bleeding and a higher rate of amenorrhea .

38. 38 NORPLANT–II (Jadelle): Two rods of 4 cm long with diameter of 2.5 mm is used. Each rod contains 75 mg of levonorgesterel. It releases 50 mcg of levonorgestrel per day. Contraceptive efficacy is similar to combined pills. Failure rate is 0.06 per 100 women years. It is used for 3 years. The rods are easier to insert and remove.

39. Mechanism of action M OA Similar to the Norplant System . causes ovulation suppression. Cervical mucus thickening making it difficult for the sperms to pass through . An atrophic endometrium caused by suppression of the estradiol- induced cyclic maturation of the endometrium Reduction of tubal motility Implanon system rod 39

40. 40 Factors that determine MOA Norplant Within 24 hours after insertion of Norplant, plasma concentrations of levonorgestrel range from 0.4 to 0.5 ng/mL, high enough to prevent conception; however, a study of cervical mucus changes indicates that a backup method should be used for 3 days after insertion. The release rate of the contraceptive implants is determined by total surface area and the density of the implant in which the progestin is contained .

41. The rate of release is dependent on time ie within the first 6- 12 months 86 µg of levonorgestrel is released per 24 hours. This rate decreases gradually to 50 µg daily by 9 months and 30 µg per day for the remaining duration of use. Levonorgestrel levels can also be affected by the circulating levels of sex hormone- binding globulin (SHBG). Levonorgestrel has a high affinity for SHBG.

42. 42 Body weight affects the circulating levels of levonorgestrel; the greater the weight of the user, the lower the levonorgestrel concentrations at any time during Norplant use. The greatest decrease over time occurs in women weighing more than 70 kg , but even for heavy women, the release rate is high enough to prevent pregnancy at least as reliably as oral contraceptives.

43. 43 Insertion & removal of implanon . Insertion: Subdermally in the non dorminant arm 6- 8 cm above the elbow fold. No incision is required. Done under local anesthe sia . Its inserted within Day 5 of a menstrual cycle, immediately after abortion and 3 weeks after postpartum. It is inserted between biceps and triceps muscles. Sites of insertion upper leg, forearm, and upper arm (nondominant, upper, inner arm is the best site) Removal: Removal is done by making a 2 mm incision at the tip of the implant and pushing the rod until it pops out. should be removed within 3 years of insertion. Loss of contraceptive action is immediate. Circulating levels of progestin become too low to measure within 48 hours after removal of implants. Most women resume normal ovulatory cycles during the first month after removal.

44. 44 Advantages. Compliance is achieved as compared to oral pill burden. There are no forgotten pills, broken condoms, lost diaphragms, or missed injections Used safely during lactation It increases the milk secretion without altering its composition. Protective against endometrial cancer and ovarian cancer Highly effective for long- term use and rapidly reversible. Suited for women who have completed their family but do not desire permanent sterilization. This safe and effective method is considered as ‘reversible sterilization’.

45. 45 ADVANTAGES OF IMPLANON Very high level of protection against pregnancy Easy to use only 1 in 3 years is sufficient Used safely between 18- 45 years Breast feeding women – Safe Cigarette smokers – Safe Need no regular attention No side effects connected to estrogen Fertility return within 3 months of removal

46. 46 Side effects Frequent irregular menstrual bleeding due to the presence of enlarged venous sinusoids (fragile vessels) and a reduction in the expression of a protein factor involved in the initiation of hemostasis spotting due to endometrium regress ion to an atrophic state after insertion. Amenorrhea Metro rr hagia Difficulty in removal is felt occasionally. Surgical application Pain, redness, sensitivity in the area of application Severe headache Weight gain 3- 12%

47. 47 Injectable contraceptives is not suitable if Think you might be pregnant. Want to keep having regular periods. Have bleeding in between periods or after sex. Have arterial disease or a history of heart disease or stroke Have a blood clot in a blood vessel (thrombosis) Have liver disease. Have migraines. Have breast cancer or have had it in the past. Have diabetes with complications. Have cirrhosis or liver tumours. Are at risk of osteoporosis.

48. 48 Absolute Contraindications current breast cancer. Pregnancy. Unexplained genital bleeding. Severe coagulation disorders. Previous sex steroid- induced liver adenoma.

49. INTRAUTERINE CONTRACEPTIVE DEVICES (IUCDs ) The device is classified as open , when it has got no circumscribed aperture of more than 5 mm so that a loop of intestine or omentum cannot enter and become strangulated if, accidentally, the device perforates through the uterus into the peritoneal cavity. Lippes loop, Cu T, Cu 7, Multiload and Progestasert are examples of open devices. If closed devices , like Grafenberg ring and Birnberg bow, accidentally enter the abdominal cavity, they have the potential of causing strangulation of the gut; and hence are obsolete. 46

50. The device may be non-medicated as Lippes loop or medicated (bioactive) by incorporating a metal copper, in devices like: Cu T- 380A . Cu T- 200. Multiload- 250. Multiload- 375 47

51. Contraindications for Insertion of IUCD: Presence of pelvic infection current or within 3 months Undiagnosed genital tract bleeding Suspected pregnancy Distortion of the shape of the uterine cavity as in fibroid or congenital uterine- malformation Severe dysmenorrhea Past history of ectopic pregnancy Within 6 weeks following cesarean section STIs — Current or within 3 months Trophoblastic disease; Significant immunosuppression. 48

52. 52 Time of Insertion A) Interval (When the insertion is made in the interconceptional period beyond 6 weeks following childbirth or abortion) — It is preferable to insert 2–3 days after the period is over . But it can be inserted any time during the cycle even during menstrual phase which has certain advantages (open cervical canal, distended uterine cavity, less cramp). However, during lactational amenorrhea , it can be inserted at any time.

53. 53 B) Postabortal — Immediately following termination of pregnancy by suction evacuation or D and E, or following spontaneous abortion, the device may be inserted. The additional advantage of preventing uterine synechia can help in motivation for insertion.

54. 54 C) Postpartum — Insertion of the device can be done before the patients are discharged from the hospital. Because of high rate of expulsion, it is preferable to withhold insertion for 6 weeks when the uterus will be involuted to near normal size. D) Postplacental delivery Insertion immediately following delivery of the placenta could be done. But the expulsion rate is high .

55. 55 Indications for removal: Persistent excessive regular or irregular uterine bleeding Flaring up of salpingitis Perforation of the uterus IUD has come out of place (partial expulsion) Pregnancy occurring with the device in situ Woman desirous of a baby Missing thread One year after menopause When effective lifespan of the device is over . IUD removal is simple and can be done at any time. It is done by pulling the strings gently and slowly with a forceps.

56. Device expelled outside unnoticed by the patient Missing Thread: The thread may not be visible through the cervical os due to — Thread coiled inside Thread torn through Device perforated the uterine wall and is lying in the peritoneal cavity Device pulled up by the growing uterus in pregnancy .

57. Methods of identification: Pregnancy is to be excluded first — Ultrasonography can detect the IUD either within the uterine cavity or in the peritoneal cavity (if perforated). It is preferred to radiography. Hysteroscopy can be used for direct visualization of the uterine cavity and it could be removed simultaneously. Sounding the uterine cavity by a probe. If negative, straight X-ray after introducing radiopaque probe (uterine sound) into the uterine cavity. This will not only reveal the presence or absence of the device but it also exists outside uterine cavity.

58. IUD (Cu devices and Hormone releasing IUDs) Advantages Inexpensive : Cu T- distributed free of cost through Government channel Simplicity in techniques of insertion and most cost effective of all methods Prolonged contraceptive protection after insertion (5–10 years) and suitable for the rural population of developing countries Systemic side effects are nil. Suitable for hypertensives, breastfeeding women and epileptics 5. Reversiblity to fertility is prompt after removal Disadvantages 1. Require motivation 2. Limitation in its use 3. Adverse local reactions manifested by menstrual abnormalities, PID, pelvic pain and heavy periods. Beside effects are less with third generation of IUDs 4. Risk of ectopic pregnanc y Failure rate 0.1-2 (HWY) 54

59. 59 Removal A. Device inside the uterine cavity: It can be removed by any of the following methods mentioned below : Especially designed blunt hook Artery forceps. Uterine curette Hysteroscopically under direct vision . B. Outside the uterus but inside the abdominal cavity : Laparoscopy. Laparotomy (rarely).

60. 60 Cu T 380A Cu T 380A carries total 380 mm2 surface area of copper wire wound around the stem (314 mm2) and each copper sleeve on the horizontal arms (33 mm2). The frame contains barium sulfate and is radiopaque. Replacement is every 10 years.

61. 61 Mechanism of action of CuT- 380A The contraceptive action of all IUDs is mainly in the uterine cavity. Ovulation is not affected IUD causes a sterile inflammatory response, which produces tissue injury of a minor degree but sufficient enough to be spermicidal Inflamatory response leads to production in the endometrium of cytokine peptides known to be cytotoxic . Lysosomal disintegration from the macrophages attached to the device liberates prostaglandins , which are toxic to spermatozoa .

62. 62 MOA CONT. There is intense local inflammatory response induced in the uterus by copper- containing devices which leads to lysosomal activation and other inflammatory actions that are spermicidal In the unlikely event that fertilization does occur, the same inflammatory actions are directed against the blastocyst a nd finally, the endometrium becomes hostile to implantation. The altered intrauterine environment interferes with sperm passage rough the uterus, preventing fertilization .

63. 63 Contra indication to CuT- 380A Pregnancy or suspicion of pregnancy Uterine abnormality with distorted uterine cavity Acute PID, or current behavior suggesting a high risk for PID Postpartum or postabortal endometritis in last 3 months Known or suspected uterine or cervical malignancy Genital bleeding of unknown etiology Mucopurulent cervicitis Wilson disease Allergy to any component of ParaGard A previously placed IUD that has not been removed Severe dysmenorrhea Past history of ectopic pregnancy Trophoblastic disease

64. 64 Levonorgestrel intrauterine system (LNG-IUS) This is a T- shaped device, with polydimethylsiloxane membrane around the stem which acts as a steroid reservoir. Total amount of levonorgestrel is 52 mg and is released at the rate 20 μg/day. This device is to be replaced every 7 years. Its efficacy is comparable to sterilization. It has many non-contraceptive benefits also

65. 65 Levonorgestrel- IUS (Mirena) It induces strong and uniform suppression of endometrium. Cervical mucus becomes very scantly. Anovulation and insufficient luteal mentioned. phase activity has also been Serum progesterone level is not increased.

66. 66 mechanisms by which LNG- IUS may prevent pregnancy The progestin renders the endometrium atrophic; it stimulates thick cervical mucus that blocks sperm penetration into the uterine cavity; Decrease tubal motility, thereby preventing ovum and sperm union. note ectopic pregnancy may be at increased risk because of diminished tubal motility from progestin action expulsion rate to be approximately 10 percent in women with coexistent leiomyomas .

67. 67 Contraindications for LND- IUS Pregnancy or suspicion of pregnancy Uterine abnormality with distorted uterine cavity Use for postcoital contraception Acute PID or history of, unless there has been a subsequent intrauterine pregnancy Postpartum endometritis or infected abortion in the past 3 months Known or suspected uterine or cervical neoplasia Uterine bleeding of unknown etiology Untreated acute cervicitis or vaginitis or other lower genital tract infections Acute liver disease or liver tumor (benign or malignant) Increased susceptibility to pelvic infection A previously placed IUD that has not been removed Hypersensitivity to any component of the device Known or suspected breast cancer or other progestin sensitive cancer

68. 68 Side effects / Complications CuT IUD menses may be heavier and longer. LNG IUD the high doses of progestin profoundly change the endometrium, which is reflected in the user’s bleeding patterns. Women generally experience frequent episodes of unscheduled bleeding and spotting in the early months, following which bleeding becomes rare. By 12 months , 20% of women have no bleeding or spotting, and the most common pattern seen is 1 to 3 days of spotting a month. Hence , hemoglobin levels decrease . Iron supplement is advocated. Tranexamic acid may be given for short- term relief.

69. 69 Immediate: Cramp like pain Syncopal attack— often found in nulliparous or when the device is large enough to distend the uterine cavity. Partial or complete perforation —due to faulty technique of insertion Pelvic infection (PID) — The risk of developing PID is 2–10 times greater amongst IUD users. Spontaneous expulsion— more rates following postabortal or puerperal insertions. Perforation of the uterus— The incidence of uterine perforation is about 1 in 1000 insertions. Most perforations occur at the time of insertion but the migration may also occur. Migration of Copper device — A copper bearing device induces an intense local inflammatory reaction with adhesions with the surrounding structures. Remove by laparoscopy or laparotomy.

70. HORMONAL CONTRACEPTIVES 70 Combined Oral Cntraceptive Pills (OCPs). Progesterone only Contraceptives Progesterone only pills Injectables Implants IUD (MIRENA) Newer Combined Hormonal Methods: Rings patches

71. 71 COMBINED ORAL CONTRACEPTIVES (PILLS) The combined oral steroidal contraceptives is the most effective reversible method of contraception. In the combination pill, the commonly used progestins are either levonorgestrel or norethisterone or desogestrel and the estrogens are principally confined to either ethinyl-estradiol or menstranol (3 methylether of ethinylestradiol). Currently ‘lipid friendly’, third generation progestins , namely desogestrel, gestodene, norgestimate are available.

72. 72 Mode of action: The probable mechanism of contraception are: • Inhibition of ovulation — Both the hormones synergistically act on the hypothalamopituitary axis. The release of gonadotropin releasing hormones from the hypothalamus is prevented through a negative feedback mechanism. There is thus no peak release of FSH and LH from the anterior pituitary. So follicular growth is either not initiated or if initiated, recruitment does not occur. • Producing static endometrial hypoplasia — There is stromal edema, decidual reaction and regression of the glands making endometrium nonreceptive to the embryo .

73. • Alteration of the character of the cervical muc (thick, viscid and scanty) so as to prevent sperm penetration. • Probably interferes with tubal motility and alters tubal transport. Thus, even though accidental breakthrough ovulation occurs, the other mechanisms prevent conception. Estrogen inhibits FSH rise and prevents follicular growth. It is also useful for better cycle control and to prevent breakthrough bleeding. Progestin: Anovulatory effect is primarily by inhibiting LH surge. It is also helpful to counteract the adverse effects of estrogen on the endometrium (endometrial hyperplasia and heavy withdrawal bleeding). It is also responsible for changes In the cervical mucus (vide supra).

74. Contraceptive eligibility 69

75. 75 Non- contraceptive benefits of cocs: Improvement of menstrual abnormalities : Regulation of menstrual cycle Reduction of dysmenorrhea (40%) Reduction of menorrhagia (50%) Reduction of premenstrual tension syndrome (PMS) Reduction of Mittelschmerz’s syndrome. Protection against iron- deficiency anemia

76. 76 Protection against health disorders Pelvic inflammatory disease (thick cervical mucus) Ectopic pregnancy Endometriosis Fibroid uterus Hirsutism and acne Functional ovarian cysts Benign breast disease Osteopenia and postmenopausal osteoporotic fractures Autoimmune disorders of thyroid Rheumatoid arthritis.

77. 77 Prevention of malignancies Endometrial cancer (50 %) Epithelial ovarian cancer (50 %) Colorectal cancer (40%).

78. CONDOM (MALE): Condoms are made of polyurethane or latex . Polyurethane condoms are thinner and suitable to those who are sensitive to latex rubber . It is the most widely practised method used by the male. Protection against sexually transmitted disease is an additional advantage . Occasionally, the partner may be allergic to latex. The method is suitable for couples who want to space their families and who have contraindications to the use of oral contraceptive or IUD . e i n f r eque n t sexual inte r c o u r 7 3 s e . • Th e s e a 3 re also suitable to those who ha v 3 / 1 4

79. 74 MALE CONDOM The condom, or contraceptive sheath , prevents the deposition of semen in the vagina . It is made of latex , polyurethane material and lamb ceca. The advantages of the condom are that it provides highly effective and inexpensive contraception as well as protection against sexually

80. 75 Some condoms now contain a spermicide , which may offer further protection against failure, particularly if the condom breaks. Given the concern about STIs, including human immunodeficiency virus (HIV), condom use should be recommended for all couples except those in a mutually monogamous relationship. The condom probably is the most widely used mechanical contraceptive in the world today. Condoms made of latex or polyurethane are impervious to both sperm and most bacterial and viral organisms that cause STIs or HIV infection. However, the less commonly used lamb's cecum condom is not impermeable to such organisms.

81. 81 Advantages of condom Cheaper with no contraindications No side effects Easy to carry, simple to use and disposable Protection against sexually transmitted diseases, e.g. gonorrhea, chlamydia, HPV and HIV Protection against pelvic inflammatory diseases Reduces the incidence of tubal infertility and ectopic pregnancy Protection against cervical cell abnormalities Useful where the coital act is infrequent and irregular

82. 82 Disadvantages of condom May accidentally break or slip off during coitus Inadequate sexual pleasure Allergic reaction (Latex) To discard after one coital act Failure rate — 15 (HWY)

83. 83 Basic steps of using the male condom Five basic steps when using a male condom. (A Global Handbook for Providers, WHO, 2007) Use a new condom for each act of sex. Before any physical contact, place the condom on the tip of the erect penis with the rolled side out. Unroll the condom all the way to the base of the erect penis Immediately after ejaculation, hold the rim of the condom in place and withdraw the penis while it is still erect Dispose of the used condom safely.

84. 84

85. FEMALE CONDOM A famale condom is a thin, loose- fitting and flexible plastic tube worn inside the vagina. It has inner and outer rings It has soft ring at the closed end of the tube which covers the cervix during intercourse and h olds it inside the vagina. Another ring at the open end of the tube stays outside the vagina and partly covers the lip area. 85

86. 86 MECHANISM OF ACTION The female condom helps protect partners from pregnancy and STIs, including HIV/AIDS. It is the only female- controlled device offering this protection . It provides a barrier between partners during sexual intercourse, to prevent the sharing of bodily fluids, like semen and blood. This ensures that pregnancy does not occur, and STIs are not transmitted.

87. 87 HOW TO INSERT Can be inserted up to 8 hours before intercourse, and are only effective when placed prior to intercourse. Note that a female condom and a male condom should not be used at the same time, because this can cause friction that may lead to slipping or tearing of the condoms.

88. 88 Steps of insertion squeeze the ring at the closed end of the tube. use other hand to spread the outer lips, and insert the squeezed condom into the vaginal canal. – The inner ring should be pushed just past the pubic bone and over the cervix. After insertion, make sure the condom is not twisted. About one inch of the open end will stay outside the body. The outer ring of the female condom needs to be held in place during intercourse. After intercourse, squeeze and twist the outer ring to keep all fluids, including sperm, inside the condom, and gently pull it out and throw it away.

89. 89

90. 90

91. 91 ADVANTAGES Unlike the male condom, erection is not necessary to keep the condom in place. Female condoms do not reduce a male partner’s stimulation. Female condoms can be used by people who are known to be sensitive to latex because, while most male condoms are made of latex, female condoms are made of plastic, which rarely causes an allergic reaction.

92. 92 DISADVANTAGES Female condoms make a noticeable sound during sexual intercourse. It is sometimes difficult to insert or use, and some women can have difficulty on the first attempt at self- insertion. It can break or leak. It is much more expensive than a male condom.

93. 93 As an elective contraceptive method As an interim form of contraception during pill use, following vasectomy operation and if an IUD is thought lost until a new IUD can be fitted; During the treatment of trichomonal vaginitis of the wife, the husband should use it during the course of treatment irrespective of contraceptive practice; Immunological infertility male partner to use for 3 months. USES OF CONDOMS

94. COITUS INTERRUPTUS One of the oldest contraceptive methods is withdrawal of the penis before ejaculation. This process results in deposition of the semen outside the female genital tract . It has the disadvantage of demanding sufficient self- control by the man so that withdrawal precedes ejaculation. Although the failure rate probably is higher than that of most methods, reliable statistics are not available. Failure may result from escape of semen before orgasm or the deposition of semen on the external female genitalia near the vagina. 94

95. LACTATIONAL AMENORRHEA The lactational amenorrhea method can be a highly efficient method for breastfeeding women to use physiology to space births. Suckling results in in the release of gonadotropin- releasing a reduction hormone, luteinizing hormone (LH), and follicle-stimulating hormone (FSH). β-Endorphins induced by suckling also induce a decline in the secretion of dopamine , which normally suppresses the release of prolactin. 95

96. Elevated prolactin levels and a reduction of gonadotropin- releasing hormone from the hypothalamus during lactation suppress ovulation . This leads to a reduction in luteinizing hormone (LH) release and inhibition of follicular maturation. 96 This results in a condition of amenorrhea and anovulation. •

97. 97 The duration of this suppression varies and is influenced by the frequency and duration of breastfeeding and the length of time since birth . Mothers must utilize breastfeeding only to be successful. During the first 6 months , if breastfeeding is exclusive , menses are mostly anovulatory and fertility remains low. However, as soon as the first menses occurs , she must begin to use another method of birth control to avoid pregnancy.

98. A recent World Health study Organization (WHO) on lactational revealed that during amenorrhea the first 6 months of nursing , cumulative pregnancy rates ranged from 0.9 to 1.2%. However, at 12 months , pregnancy rates rose as high as 7.4%. When using lactation as a method of birth control, the mother must provide breastfeeding as the only form of infant nutrition. 98

99. 99 Supplemental feedings may alter both the pattern of lactation and the intensity of infant suckling , which secondarily may affect suppression of ovulation. Second , amenorrhea must be maintained . Finally, the method should be practiced as the only form of birth control for a maximum of 6 months after birth. If another pregnancy is undesired, most practitioners advise lactating women to use a reliable contraceptive method starting 3 months after delivery .

100. 100 Efficacy: Perfect use failure rate within the first 6 months is 0.5%. Typical use failure rate within the first 6 months is 2%.

101. Advantages: Involution of the uterus occurs more rapidly. Menses are suppressed. This method can be used immediately after childbirth. This method facilitates postpartum weight loss. Disadvantages: Return to fertility is uncertain. Frequent breastfeeding may be inconvenient. This method should not be used if the mother is HIV positive. 101

102. Vaginal Contraceptives Spermicides: Spermicides are available as vaginal foams, gels, creams , tablets and suppositories. Usually, they contain surfactants like nonoxynol–9, octoxynol or benzalkonium chloride. These agents mostly cause sperm immobilization. The cream or jelly is introduced high in the vagina with the help of the applicator soon before coitus. Foam tablets (1–2) are to be introduced high in the vagina at least 5 minutes prior to intercourse. In isolation, it is not effective (18–29 HWY), but enhances the efficacy of condom or diaphragm when used along with it. There may be occasional local allergic manifestations either in the vagina or vulva . Fig. 35.1C: Vaginal contraceptive (Nonoxynol–9, 12.5%) 102

103. Vaginal contraceptive sponge (Today) : It is made of polyurethane impregnated with 1 g of nonoxynol- 9 as a spermicide . Nonoxynol- 9 acts as a surfactant which either immobilizes or kills sperm . It releases spermicide during coitus , absorbs ejaculate and blocks the entrance to the cervical canal . The sponge should not be removed for 6 hours after intercourse. Its failure rate (HWY) is about — Parous women: 32- 20, Nulliparous 16- 9 . Currently it is observed that nonoxynol–9 is not effective in preventing cervical gonorrhea, chlamydia or HIV infection. Moreover, it produces lesions in the genital tract when used frequently. Those lesions are associated with increased risk of HIV transmission. 103

104. 104 FERTILITY AWARENESS- BASED METHODS These family planning methods attempt to identify the fertile days each cycle and advise sexual abstinence during these days. Common forms of these fertility awareness- based (FAB) methods include: Standard Days . Temperature Rhythm . Cervical Mucus, and Symptothermal Methods. .

105. 105 The Standard Days Method counsels women to avoid unprotected intercourse during cycle days 8 through 19 . For successful use, women must have regular monthly cycles of 26 to 32 days. Those who use this method can mark a calendar or can use Cycle- Beads , which is a ring of counting beads, to keep track of their days.

106. The Temperature Rhythm Method relies on a sustained 0.4°F rise in the basal body temperature , which usually precedes ovulation. For maximum efficacy, the woman must abstain from intercourse from the first day of menses through the third day after the temperature increase . 106

107. The Cervical Mucus Method , also called the Two- Day Method or 107 Billings Method, relies on awareness of vaginal “dryness” and “wetness.” These reflect changes in the amount and quality of cervical mucus at different times in the menstrual cycle. With the Billings Method, abstinence is required from the beginning of menses until 4 days after slippery mucus is identified. With the Two- Day Method, intercourse is considered safe if a woman did not note mucus on the day of planned intercourse or the day prior.

108. The Symptothermal Method combines changes in cervical mucus— onset of fertile period; changes in basal body temperature— end of fertile period; and calculations to estimate the time of ovulation. 108

109. Fertility Awareness Method: Fertility Awareness Method requires partner’s cooperation . The woman should know the fertile time of her menstrual cycle. Rhythm Method: This is the only method approved by the Roman Catholic Church. The method is based on identification of the fertile period of a cycle and to abstain from sexual intercourse during that period . This requires partner’s cooperation. The methods to determine the approximate time of ovulation and the fertile period include — recording of previous menstrual cycles ( calendar rhythm ) noting the basal body temperature chart ( temperature rhythm ) noting excessive mucoid vaginal discharge ( mucus rhythm ). 109

110. 110 The users of the calendar method obtain the period of abstinence from calculations based on the previous twelve menstrual cycle records. The first unsafe day is obtained by subtracting 20 days from the length of the shortest cycle and last unsafe day by deducting 10 days from the longest cycle. Users of temperature rhythm require abstinence until the third day of the rise of temperature. Users of mucus rhythm require abstinence on all days of noticeable mucus and for 3 days thereafter.

111. 111 Fertility awareness methods (Rhythm method) Advantages No cost No side effects Failure rate — 20–30 (HWY) Disadvantages Difficult to calculate the safe period reliably Needs several months training to use these methods Compulsory abstinence from sexual act during certain periods Not applicable during lactational amenorrhea or when the periods are irregular.

112. 112 Coitus Interruptus (withdrawal) It is the oldest and probably the contraceptive method used by man. most widely accepted It necessitates withdrawal of penis shortly before ejaculation . It requires sufficient self- control by the man so that withdrawal of penis precedes ejaculation

113. Coitus interruptus Advantages No appliance is required No cost. Failure rate— 27 (HWY) Disadvantages Requires sufficient self control by the man The woman may develop anxiety neurosis, vaginismus or pelvic congestion Chance of pregnancy is more : (a) Precoital secretion may contain sperm (b) Accidental chance of sperm deposition in to the vagina. 109

114. 114 Breastfeeding , Lactational amenorrhea (LAM): Prolonged and sustained breastfeeding offers a natural protection of pregnancy. This is more effective in women who are amenorrheic than those who are menstruating . The risk of pregnancy to a woman who is fully breastfeeding and amenorrheic is less than 2 percent in the first 6 months . Otherwise, the failure rate is high (1–10 percent). Thus during breastfeeding, additional contraceptive support should be given by condom, IUCD or injectable steroids where available to provide complete contraception. When the women is full breastfeeding , a contraceptive method should be used in the 3rd postpartum month and with partial or no breastfeeding , she should use it in the 3rd postpartum week .

115. References; 1.The essentials of contraceptive technology baltimore , johnshopkins Bloomberg school of public health, population information program (1997 ). 2. FAMILY PLANNING, Aglobal Handbook For Providers, evidence based guidance developed through worldwide collaboration(2007).